ABCDDV/1049
ABCD Arq Bras Cir Dig 2014;27(4):237-242 DOI:http://dx.doi.org/10.1590/S0102-67202014000400003
Artigo Original
Impact OF MINIMALLY INVASIVE SURGERY in the treatment of esophageal cancer Impacto da cirurgia minimamente invasiva no tratamento de câncer de esôfago Italo BRAGHETTO M; Gonzalo CARDEMIL H; Carlos MANDIOLA B; Gonzalo MASIA L; Francesca GATTINI S.
From the Department of Surgery, Faculty of Medicine, “Dr. José Joaquín Aguirre” Universidad de Chile Clinical Hospital, Universidad de Chile, Santiago, Chile
DESCRITORES - Neoplasia esofágica. Câncer. Esofagectomia. Videotoracoscopia.
Correspondence: Italo Braghetto E-mail: [email protected] Financial source: none Conflicts of interest: none Received for publication: 16/04/2014 Accepted for publication: 24/07/2014
HEADINGS - Esophageal neoplasm. Cancer. Esophagectomy. Videotoracoscopy.
ABSTRACT - Background: Surgical treatment of esophageal cancer is associated to a high morbidity and mortality rate. The open transthoracic or transhiatal esophagectomy are considerably invasive procedures and have been associated to high rates of complications and operative mortality. In this way, minimally invasive esophageal surgery has been suggested as an alternative to the classic procedures because would produce improvement in clinical longterm postoperative outcomes. Aim: To assess survival, mortality and morbidity results of esophagectomy due to esophageal cancer submitted to minimally invasive techniques and compare them to results published in international literature. Method: An observational, prospective study. Between 2003 and 2012, 69 patients were submitted to a minimally invasive esophagectomy due to cancer. It was recorded postoperative morbidity and mortality according to the Clavien-Dindo classification. The survival rate was analyzed with the KaplanMeier method. The number of lymph nodes obtained during the lymph node dissection, as an index of the quality of the surgical technique, was analysed. Results: 63.7% of patients had minor complications (type I-II Clavien Dindo), while nine (13%) required surgical reexploration. The most common postoperative complication corresponded to leak of the cervical anastomosis seen in 44 (63.7%) patients but without clinical repercusion, only two of them required reoperation. The mortality rate was 4.34%, and reoperation was necessary in nine (13%) cases. The average survival time was 22.59±25.38 months, with the probability of a 3-year survival rate estimated at 30%. The number of resected lymph nodes was 17.17±9.62. Conclusion: Minimally invasive techniques have lower morbidity and mortality rate, very satisfactory lymphnodes resection and similar long term outcomes in term of quality of life and survival compared to results observed after open surgery.
RESUMO - Racional: O tratamento cirúrgico do câncer de esôfago está associado com alta morbidade e mortalidade. Os acessos transtorácicos abertos ou os transmediastinais são considerados procedimentos invasivos e têm sido associados à altas taxas de complicações e de mortalidade operatória. Desta forma, a operação do esôfago minimamente invasiva tem sido sugerida como alternativa aos procedimentos clássicos, porque iria produzir melhora no desempenho pós-operatório a longo prazo. Objetivo: Avaliar a sobrevida, mortalidade e morbidade da esofagectomia por câncer de esôfago submetidos às técnicas minimamente invasivas e compará-los com os resultados publicados na literatura internacional. Método: Estudo observacional, prospectivo. Entre 2003 e 2012, 69 pacientes foram submetidos à esofagectomia minimamente invasiva devido ao câncer. Foram analisadas morbidade e mortalidade pós-operatória de acordo com a classificação Clavien-Dindo. A taxa de sobrevivência foi analisada pelo método de Kaplan-Meier. O número de nódulos linfáticos obtidos durante a dissecção do nódulo linfático foi analisado como um índice da qualidade da técnica cirúrgica. Resultados: 63,7% dos pacientes tiveram complicações menores (tipo I-II Clavien Dindo), enquanto nove (13%) necessitaram de re-exploração cirúrgica. A complicação pós-operatória mais comum correspondeu a deiscência da anastomose cervical observada em 44 (63,7%) pacientes, mas sem suas repercussões clínicas, apenas dois deles necessitaram de reoperação. A taxa de mortalidade foi de 4,34%, e reoperação foi necessária em nove (13%) casos. O tempo médio de sobrevivência foi de 22,59±25,38 meses, com a probabilidade de uma taxa de sobrevida em três anos estimada em 30%. O número de linfonodos ressecados foi 17,17±9,62. Conclusão: As técnicas minimamente invasivas têm menor morbidade e mortalidade, satisfatório número de linfonodos ressecados e resultados a longo prazo semelhantes após operação aberta, em termos de qualidade de vida e sobrevida.
INTRODUCTION
S
urgical treatment of esophageal cancer is associated to a high morbidity and mortality rate, even in specialized centers. An open transthoracic or transhiatal esophagectomy are the most common procedures performed in order to treat this disease1-3 . Both procedures are considerably invasive and have been associated to high rates of complications and operative mortality1,3-5 Notwithstanding, although an open transhiatal esophagectomy with gastric mobilization and cervical anastomosis theoretically presents less surgical trauma, it has significant limitations with regards to the feasibility of resecting the middle third of the esophagus along
ABCD Arq Bras Cir Dig 2014;27(4):237-242 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercia License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
237
Original Article
with an inadequate dissection of lymph nodes on this level, in addition to an increased risk of lesions in the adjacent structures which can reach up to 50% in some cases, and a mortality rate of 8 to 23%6-8. I n t h i s w a y, m i n i m a l l y i n v a s i v e e s o p h a g e a l surger y has been suggested as an alternative to the classic procedures that are generally performed since it represents less surgical trauma, a lower risk of bleeding, and a lymphadenectomy performed more carefully, thus potentially implying an improvement in clinical outcomes and postoperative remote patient outcomes. In recent years, a progressive increase has been observed in the number of centers that use this procedure as their surgical approach of choice 9,10. However, their results have not been well established with regards to the long term prognosis from an oncological point of view. The objective of this study is to assess sur vival, mortality and morbidity results of an esophagectomy due to cancer during its different clinical stages through minimally invasive techniques, and compare them to results published in international literature.
METHOD An observational, prospective study in which the clinical results of 69 patients submitted to a minimally invasive esophagectomy due to cancer was recorded, between 2003 and 2012, at the Department of Surgery at the University of Chile Hospital. All patients were subjected to a preoperative study protocol which included an upper GI endoscopy with biopsy, a barium x-ray study, CT scans of the chest, abdomen and pelvis, cardiopulmonary function tests, nutritional assessment and clinical staging of the esophageal cancer according to TNM classification. Was employed a transthoracic esophagectomy, and the transit reconstruction techniques used consider gastric tubulization and mobilization by laparoscopic approach in the majority of patients or the ascendant colon interposition using open procedure in those patients when it was not possible to used stomach. Pe r i o p e r a t i v e m o r b i d i t y w a s d e f i n e d a s t h e complications that arose up until the 30th postoperative day and were analyzed according to the Clavien-Dindo classification11. Late complications were defined as those which are unrelated at the time of the surgical procedure and that presented themselves as of the 31st postoperative day. In the same way, operative mortality was defined as an event occurring up to the 30th postoperative day. The survival rate was analyzed with the Kaplan-Meier calculator, determined in a general manner and by clinical-pathological stage based on the 2010 guide updated and reviewed by the American Joint Committee on Cancer12. Furthermore, an analysis was performed of the number of lymph nodes obtained during the lymph node dissection, as an index of the quality of the surgical technique. The statistical analysis and record of the data was carried out using Excel Microsoft Office 2010 program, obtaining the Kaplan Meier curves with the MedCalc 12.3.0.0 program. The comparison between the survival curves was performed using the Log-Rank method, establishing statistical significance as p
ABCD Arq Bras Cir Dig 2014;27(4):237-242 DOI:http://dx.doi.org/10.1590/S0102-67202014000400003
Artigo Original
Impact OF MINIMALLY INVASIVE SURGERY in the treatment of esophageal cancer Impacto da cirurgia minimamente invasiva no tratamento de câncer de esôfago Italo BRAGHETTO M; Gonzalo CARDEMIL H; Carlos MANDIOLA B; Gonzalo MASIA L; Francesca GATTINI S.
From the Department of Surgery, Faculty of Medicine, “Dr. José Joaquín Aguirre” Universidad de Chile Clinical Hospital, Universidad de Chile, Santiago, Chile
DESCRITORES - Neoplasia esofágica. Câncer. Esofagectomia. Videotoracoscopia.
Correspondence: Italo Braghetto E-mail: [email protected] Financial source: none Conflicts of interest: none Received for publication: 16/04/2014 Accepted for publication: 24/07/2014
HEADINGS - Esophageal neoplasm. Cancer. Esophagectomy. Videotoracoscopy.
ABSTRACT - Background: Surgical treatment of esophageal cancer is associated to a high morbidity and mortality rate. The open transthoracic or transhiatal esophagectomy are considerably invasive procedures and have been associated to high rates of complications and operative mortality. In this way, minimally invasive esophageal surgery has been suggested as an alternative to the classic procedures because would produce improvement in clinical longterm postoperative outcomes. Aim: To assess survival, mortality and morbidity results of esophagectomy due to esophageal cancer submitted to minimally invasive techniques and compare them to results published in international literature. Method: An observational, prospective study. Between 2003 and 2012, 69 patients were submitted to a minimally invasive esophagectomy due to cancer. It was recorded postoperative morbidity and mortality according to the Clavien-Dindo classification. The survival rate was analyzed with the KaplanMeier method. The number of lymph nodes obtained during the lymph node dissection, as an index of the quality of the surgical technique, was analysed. Results: 63.7% of patients had minor complications (type I-II Clavien Dindo), while nine (13%) required surgical reexploration. The most common postoperative complication corresponded to leak of the cervical anastomosis seen in 44 (63.7%) patients but without clinical repercusion, only two of them required reoperation. The mortality rate was 4.34%, and reoperation was necessary in nine (13%) cases. The average survival time was 22.59±25.38 months, with the probability of a 3-year survival rate estimated at 30%. The number of resected lymph nodes was 17.17±9.62. Conclusion: Minimally invasive techniques have lower morbidity and mortality rate, very satisfactory lymphnodes resection and similar long term outcomes in term of quality of life and survival compared to results observed after open surgery.
RESUMO - Racional: O tratamento cirúrgico do câncer de esôfago está associado com alta morbidade e mortalidade. Os acessos transtorácicos abertos ou os transmediastinais são considerados procedimentos invasivos e têm sido associados à altas taxas de complicações e de mortalidade operatória. Desta forma, a operação do esôfago minimamente invasiva tem sido sugerida como alternativa aos procedimentos clássicos, porque iria produzir melhora no desempenho pós-operatório a longo prazo. Objetivo: Avaliar a sobrevida, mortalidade e morbidade da esofagectomia por câncer de esôfago submetidos às técnicas minimamente invasivas e compará-los com os resultados publicados na literatura internacional. Método: Estudo observacional, prospectivo. Entre 2003 e 2012, 69 pacientes foram submetidos à esofagectomia minimamente invasiva devido ao câncer. Foram analisadas morbidade e mortalidade pós-operatória de acordo com a classificação Clavien-Dindo. A taxa de sobrevivência foi analisada pelo método de Kaplan-Meier. O número de nódulos linfáticos obtidos durante a dissecção do nódulo linfático foi analisado como um índice da qualidade da técnica cirúrgica. Resultados: 63,7% dos pacientes tiveram complicações menores (tipo I-II Clavien Dindo), enquanto nove (13%) necessitaram de re-exploração cirúrgica. A complicação pós-operatória mais comum correspondeu a deiscência da anastomose cervical observada em 44 (63,7%) pacientes, mas sem suas repercussões clínicas, apenas dois deles necessitaram de reoperação. A taxa de mortalidade foi de 4,34%, e reoperação foi necessária em nove (13%) casos. O tempo médio de sobrevivência foi de 22,59±25,38 meses, com a probabilidade de uma taxa de sobrevida em três anos estimada em 30%. O número de linfonodos ressecados foi 17,17±9,62. Conclusão: As técnicas minimamente invasivas têm menor morbidade e mortalidade, satisfatório número de linfonodos ressecados e resultados a longo prazo semelhantes após operação aberta, em termos de qualidade de vida e sobrevida.
INTRODUCTION
S
urgical treatment of esophageal cancer is associated to a high morbidity and mortality rate, even in specialized centers. An open transthoracic or transhiatal esophagectomy are the most common procedures performed in order to treat this disease1-3 . Both procedures are considerably invasive and have been associated to high rates of complications and operative mortality1,3-5 Notwithstanding, although an open transhiatal esophagectomy with gastric mobilization and cervical anastomosis theoretically presents less surgical trauma, it has significant limitations with regards to the feasibility of resecting the middle third of the esophagus along
ABCD Arq Bras Cir Dig 2014;27(4):237-242 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercia License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
237
Original Article
with an inadequate dissection of lymph nodes on this level, in addition to an increased risk of lesions in the adjacent structures which can reach up to 50% in some cases, and a mortality rate of 8 to 23%6-8. I n t h i s w a y, m i n i m a l l y i n v a s i v e e s o p h a g e a l surger y has been suggested as an alternative to the classic procedures that are generally performed since it represents less surgical trauma, a lower risk of bleeding, and a lymphadenectomy performed more carefully, thus potentially implying an improvement in clinical outcomes and postoperative remote patient outcomes. In recent years, a progressive increase has been observed in the number of centers that use this procedure as their surgical approach of choice 9,10. However, their results have not been well established with regards to the long term prognosis from an oncological point of view. The objective of this study is to assess sur vival, mortality and morbidity results of an esophagectomy due to cancer during its different clinical stages through minimally invasive techniques, and compare them to results published in international literature.
METHOD An observational, prospective study in which the clinical results of 69 patients submitted to a minimally invasive esophagectomy due to cancer was recorded, between 2003 and 2012, at the Department of Surgery at the University of Chile Hospital. All patients were subjected to a preoperative study protocol which included an upper GI endoscopy with biopsy, a barium x-ray study, CT scans of the chest, abdomen and pelvis, cardiopulmonary function tests, nutritional assessment and clinical staging of the esophageal cancer according to TNM classification. Was employed a transthoracic esophagectomy, and the transit reconstruction techniques used consider gastric tubulization and mobilization by laparoscopic approach in the majority of patients or the ascendant colon interposition using open procedure in those patients when it was not possible to used stomach. Pe r i o p e r a t i v e m o r b i d i t y w a s d e f i n e d a s t h e complications that arose up until the 30th postoperative day and were analyzed according to the Clavien-Dindo classification11. Late complications were defined as those which are unrelated at the time of the surgical procedure and that presented themselves as of the 31st postoperative day. In the same way, operative mortality was defined as an event occurring up to the 30th postoperative day. The survival rate was analyzed with the Kaplan-Meier calculator, determined in a general manner and by clinical-pathological stage based on the 2010 guide updated and reviewed by the American Joint Committee on Cancer12. Furthermore, an analysis was performed of the number of lymph nodes obtained during the lymph node dissection, as an index of the quality of the surgical technique. The statistical analysis and record of the data was carried out using Excel Microsoft Office 2010 program, obtaining the Kaplan Meier curves with the MedCalc 12.3.0.0 program. The comparison between the survival curves was performed using the Log-Rank method, establishing statistical significance as p
